Our staff looks forward to meeting you and discussing your child's pediatric care. We strive to keep our appointments on time, as scheduled. Prior to your appointment, we encourage you to fill out the patient forms below so you can accelerate your check-in process. Please download, print and complete the forms and bring them with you to your appointment. If you are unable to download our patient forms, then it is recommended that you arrive to your appointment between 15-30 minutes early so that you can have ample time to fill out the appropriate forms.
Consent to Obtain Prescription History
New Patient Paperwork
Caretaker Authorization for Medical Treatment
ImmTrac2 Minor Consent Form
Texas Immunization Registry
To easily keep up with your growing child’s vaccine records, we strongly urge all families to register their children under the Texas Immunization Registry, ImmTrac2. This vaccine registry serves as a secure system that combines your child’s records from various sources, and safely stores these documents all in one place.
To get started, your child must first be signed up for the Texas Immunization Registry, ImmTrac2. To register, please complete the minor consent form above and email back to us at [email protected] or print off and bring to their next appointment. An immunization registry account will immediately be created and your child. Consent is required one time and is valid until your child turns 18. Individuals 18 years and older must complete an adult consent form.
To have your child’s medical records sent to Village Pediatrics, please fill out the form “Authorization for Release To” below.
Authorization for Release To
Requesting Medical Records
Getting a copy of your child’s medical records has never been easier! We work with HealthMark Groupd to give you quick and easy access to medical records.
How do I submit a request for my child’s medical records?
- Visit https://requestmanager.healthmark-group.com to request medical records electronically.
- Submit your email and sign in through the link sent to your email.
- Click “Open New Request” on the menu options.
- Fill out all required fields to provide authorization to HealthMark.
You will receive an email once your medical records have been processed and are available to download.
Who should I contact for questions?
To see status updates on your records requests or to chat with support, please login through the link above. To reach out to HealthMark directly, you can call (800) 659-4035 or email support at [email protected].
*Individual results are not guaranteed and may vary from person to person. Images may contain models.